Hospitalists make in-patient care their specialty

Staff doctors relieve workload, but fragmented care could result

If you enter the hospital with pneumonia today, there's a good chance you'll be treated by a new kind of specialist - a hospitalist - instead of your family doctor.

More than half of all large U.S. medical centers now use hospitalists, and new programs are springing up across the country.

Fifteen years ago, the situation was far different: primary care doctors were in charge of treating many hospital patients. "It's a sea change in the nature of health care," says Dr. Bob Wachter, a hospitalist and researcher at the University of California at San Francisco.

Not everyone is happy about the trend. Advocates say it makes hospitals safer and more efficient, and takes pressure off overworked primary care doctors. But critics warn that the new model is further fragmenting patient care, leaving treatment in the hands of doctors who know little about their patients. As a result, they say, treatment is not only impersonal, but sometimes riskier.

Hospitalists generally care for patients who are sick enough to be hospitalized but not sick enough for intensive care. They might have pneumonia, emphysema, cancer, diabetes or some other condition that's serious, but not immediately life-threatening.

On a recent morning, for example, Dr. Aimee Wheaton, a hospitalist at Greater Baltimore Medical Center in Towson, dealt with a range of ailments.

Her first patient had been diagnosed the day before with brain cancer. After he arrived at the hospital complaining that he felt weak, a brain scan revealed a tumor. Wheaton discussed his treatment plan, asked about his nausea, and joked sympathetically with him about his inability to remember the names of his nine grandchildren.

Another patient was an electrician, admitted after complaining of dizziness. Initially, Wheaton thought he might have had a stroke or a heart problem. But tests turned up no evidence of either. Wheaton told him the good news, but advised him to start taking aspirin - a blood thinner - as a precaution against strokes.

Like most hospitalists, Wheaton specialized in internal medicine and has a broad knowledge of human organ systems. She is one of 18 hospitalists in the GBMC program, which handled more than 5,000 patients last year.

Typically, she watches over 10 or so patients. She checks them three or four times during her 10-hour shift, ordering tests, calling specialists, consulting with families and primary care doctors, and generally making sure that all the i's are dotted and t's are crossed.

Familiar territory

"We spend 100 percent of our time in this hospital," says Dr. Fred Chan, director of GBMC's program. "I know every single specialist, every single coordinator, surgeon and radiologist here."

Many patients who get hospitalist care are older, with a range of complex ailments. William Polvinale, a retired state worker from Cockeysville, is a good example.

In May, his family doctor sent him to GBMC with pneumonia. There he was cared for by hospitalist Chris Greenawalt, who prescribed antibiotics and monitored Polvinale's emphysema and high blood pressure. After four days, Polvinale was discharged.

Polvinale, 61, praised the care he got. "I didn't know [Dr. Greenawalt] at all before, but he was quite good," he said. "He was very caring and seemed to get to the problem quickly."

Almost all hospitals in the area, including Johns Hopkins Hospital, the University of Maryland Medical Center, Sinai Hospital, Franklin Square Hospital Center and Mercy Medical Center, use these specialists.

Changes in care

The movement began in the early 1990s when hospitals started hiring doctors to take care of in-patients. Hospitals had always had specialists, such as cardiologists and surgeons, but hospitalists were different. They were essentially in-house primary doctors, responsible for diagnosing problems and coordinating patient care.

The trend has grown out of several broad changes in health care over the past two decades. To cut costs, insurance companies are pushing hospitals to shorten patient stays. With most family doctors making hospital rounds only once a day, many patients were released hours or days later than necessary.

Another factor: new technologies and drugs have improved care. While that allows many patients to avoid the hospital altogether, it also means that those who do end up in the hospital tend to be sicker than before.

Meanwhile, many primary care physicians have less time for hospital visits than they once did. With HMOs squeezing payments, general practitioners have to see more patients to generate the same income. The most efficient way to do this is in the office, not at the hospital.

Together, these changes created a situation in which too many hospitalized patients didn't get regular attention. "There was a tremendous vacuum. The primary care physician was in the office all the time, and the hospital patient's care was often fragmented and inefficient," says Wachter, who coined the term "hospitalist" in a 1996 article in the New England Journal of Medicine.